MNHQ here: are you interested in the issue of medical consent during childbirth?

[RowanMumsnet]

Hello

One of the charities we work with, MASIC, is holding an event in London (sorry!) on Thursday 29 November to discuss the issue of medical consent in childbirth, and how that issue ties in to obstetric anal sphincter injuries (third or fourth degree tears that damage your anus, with often life-changing consequences) and the provision of elective caesarian sections.

It's a day-long event (9.15 to 4.30) with panels and debates on topics including:

an explanation of the Montgomery vs Lanarkshire ruling (a landmark case that established a legal standard for women's right to information about risk in childbirth);
a panel on anal injuries in childbirth and what the risk factors are (and what might be the effect of offering more caesarian sections by maternal request);
a panel entitled 'How much do we inform mothers beforehand without scaring?' [imagine there will be some strong MN views on this one...]; and
a panel called 'does consent mean anything when you're exhausted and in pain?'

Throughout the day, people who come along will be able to contribute and ask questions and generally make their views known.

Tickets are £40, or £25 for students or women with obstetric anal sphincter injuries. You can book tickets and see more info here.

We thought this would be of interest to some of you - and of course the issues being discussed are likely to interest lots of you whether you can attend or not - we at MNHQ are thinking about doing something in this area (what does it mean to give meaningful consent to procedures in childbirth, and what's the best way to ensure that women have all the information that they need to give meaningful consent) - so as ever please let us know what you think.

A member of MNHQ will be going along to represent your views, so give us a shout if you buy tickets and would like to have a coffee on the day.

Thanks
MNHQ

[StrawberryGoo]

That’s interesting liss. What did you conclude?

The thing is with the Montgomery case, as mentioned in the OP, is it wasn’t even consent in an emergency. It was a doctor who deliberately wasn’t straight with the mother about the risks to her as a diabetic of shoulder dystocia because if she had been the mother would have elected a caesarean which the doctor did not consider to be in the maternal interest. The baby got stuck and was born with significant disability.

It makes my blood boil.

[katmarie]

During my most recent delivery (just under a week ago) my midwife was amazing, however the one thing she did which pissed me off was to ask me questions mid contraction or immediately afterwards. I was using gas and air and I needed a moment post contraction to understand what she'd asked and then consider and form a response. I had to tell her this a couple of times. My birth was straightforward and still i struggled to understand and answer basic questions, and I really felt my midwife should have been aware that mid contraction was not the time to ask! If those questions had involved consent for treatment I would certainly not have been giving informed consent. I appreciate that labour and birth is a dynamic situation but surely more can be done to make sure all medical staff involved in a delivery understand the basics of obtaining and respecting consent.

In addition not telling women something because it might frighten them when they will have to deliver the baby regardless is patronising and infantalising to women. It also suggests that there are no choices or options in how we give birth, when in reality there are many. We dont keep the realities of treatment from other medical patients when seeking consent. In fact we have an obligation to present all of the facts to a patient. Why are pregnant and labouring women any different?

[Tableclothing]

I read some of Montgomery v Lanarkshire from the link in the OP. I'm not a lawyer (if there's one here please could you explain to me the bits I don't understand?) and I couldn't bring myself to read all of it (even in dry legalese it is not easy to read, at all) but....

It seemed to me that Ms Montgomery brought the case on the basis that she had not been given sufficient information to make an informed decision about her care.

[Tableclothing]

Aaargh posted too soon

[Tableclothing]

[cont from 14.42 post]

But when I read as much of the court documents as I could bear to, it seemed like even the consent that she had given was completely ignored. What I mean is, that Ms Montgomery said that she consented to attempting a vaginal delivery on the understanding that if anything went wrong an EMCS would be performed.

In the event, things went wrong and the consultant did pretty much every other intervention she could possibly think of instead. So she more or less straight against the patient's expressed wishes. I'm not sure why that didn't seem to be a bigger factor in the case.

[Veganmedic]

I’ve often mused on the consent issue but from my experience as an anaesthetist. I genuinely worry that women in labour cannot easily give informed consent when they have requested an epidural. Legally I have to cover common, rare and very rare risks and I do so with specific numbers eg 1 in 100 women are expected to get a headache etc. I pause when women are contracting to allow them the best chance of taking the information in but more often than not the woman will tell me to just get on with it. This is understandable as they are in pain and tired however it makes me nervous.
What’s the solution? We could provide the information antenatally however there are a reasonably large proportion of women who are convinced they wouldn’t want an epidural and therefore maybe wouldn’t read the information then.
I do feel a bit for obstetricians also and I’m not sure how we get round it. Forceps is a common contentious issue-nobody wants them (am currently pregnant and I’d rather not!) however a forceps delivery is far safer than a section if a woman is fully dilated and the head has descended. All I can say is that most of us genuinely want to have a safe delivery of baby and keep the mother well. It’s a really high risk area of medicine. Agree that overall a more balanced amount of information antenally would help inform women.

[StrawberryGoo]

I am a lawyer but that particular point I don’t understand - the judgment says that Mrs Montgomery agreed to a vaginal birth on the basis it would move to CS if she encountered difficulties.

However when the baby got stuck, she was put to sleep to attempt to push the baby back up for a c-section but the doctor chose to try to deliver vaginally. It is not clear why that decision was made but to be honest by that time when it really was a severe emergency she might have thought it was quicker to try to deliver vaginally. I would have to re-read it but don’t think there was any claim for negligence against the doctor for that particular decision.

Physically, it sounds horribly traumatic for Mrs Montgomery and I hope she has physically recovered from the birth, although I’m sure she is probably far more concerned about her son’s health.

[neonglow]

@Veganmedic I think that sort of thing re forceps should be discussed with women. I had high rotational forceps (no discussion, just told what they’d decided to do me whilst being wheeled to theatre) and the antenatal discussions of forceps hadn’t touched upon different types of forceps or scenarios where a c-section may be a favourable option for women. Some countries have completely abandoned forceps use altogether which does make me wonder. But all I know is for me it felt like a massive violation that other people had made a decision about what to do to my body and hadn’t been educated enough to give informed consent.

[Dinosauratemydaffodils]

I genuinely worry that women in labour cannot easily give informed consent when they have requested an epidural.

That's an interesting point. With dc1 I'd been having what I'd describe as agonising back contractions for around 70 hours when they tried to give me an epidural (for reference I've had 2 emergency sections with zero pain relief post theatre). I would have given anything to make the pain stop, in that moment with those contractions I think I'd have taken a 50/50 chance of death. I needed it to stop.

However ante-natally my intention was not to have an epidural. I'd even told dh to remind of me that in labour but I couldn't have the mobile birth I wanted because each contraction went from my back to my thighs and my leg muscles kept locking up. After I fell off the birthing ball for about the 10th time, I felt I had to be on the bed for the baby's safety and I've never been in so much pain in my life.

I had failed mid pelvis forceps followed by an emcs and really wish someone had covered that sort of scenario pre 81 hours into broken waters or at least prior to the stage when I was confused as to what my date of birth was. We were told that it would be a trial of forceps and then a section, no discussion. The risks were I think on the consent form but they weren't verbally explained and I was in no fit state to read it. I was lucky in that I only sustained some bruising (no cuts or tears) and the section went smoothly apart from the bit where I passed out having hallucinated and then had a pyschotic break but my blood, the bit they were worried about stayed inside me. I remember the Obstretrician told me I had to sign the blood transfusion form because he didn't want my husband to have to watch me bleed to death which again is hardly informed consent. It didn't help the mood in the operating theatre either.

[CentralPerkMug]

A very important issue. My midwife scared me into pushing without a contraction, which I believe caused my tear, by saying 'I'm just going to cut you now, Roly.' In what universe is that an acceptable thing to say? I was doing fine and the baby was not in distress, labour had just slowed a bit (which apparently is normal). I said something along the lines of, 'No you're bloody not' and promptly forced DD out. Totally unnecessary, but I only realised that and got annoyed about it when I thought about it afterwards

I am sorry you had such a distressing experience. However, I wonder did you have the opportunity to actually talk this through with a midwife? Sometimes midwives advise an episiotomy because they can see signs that there may be a high risk of a third degree tear - in this situation the cut needs to be done quickly before it is too late. If the head is crowning, you can definitely push the head out without a contraction but actually this is known to decrease the risk of a third degree, not increase it, because it makes the head deliver more slowly without the power of a contraction behind it.

The sad thing is that pregnant or labouring women are not treated as consenting individuals. Doctors and MW are not your friends and are not on your side. Their role is to make you, by whatever means at their disposal to deliver a "live child". They don't care about the vessel. Your consent is incidental to their policies

This is simply not true. I am sorry that you have reason to feel this way but I can promise you that this is not true. I agree that midwives are 'not your friend' as they need to build a professional relationship, not 'friendship'. However it is completely incorrect to suggest that midwives don't care about the women in their care. Last week, I looked after a woman who had suffered a stillbirth. I stayed for 3 hours after my shift was over (unpaid) to be there with her when her baby was born. The next day I brought in new pyjamas and toiletries and snacks for her as she has few family or friends in this country, bought with my own money. A few days later, I attended the funeral, on my day off, as I knew she needed support. None of these actions are unusual for me or indeed any of my colleagues. Does this sound like we don't care about women? Clearly though you have had very negative experiences and I am truly upset about that for you.

[StrawberryGoo]

centralperkmug

You sound lovely and thank you for what you do for the women you care for

[RolytheRhino]

However, I wonder did you have the opportunity to actually talk this through with a midwife?

Nope.

If the head is crowning, you can definitely push the head out without a contraction but actually this is known to decrease the risk of a third degree, not increase it, because it makes the head deliver more slowly without the power of a contraction behind it.

Not according to this:

Following your own urge to push is less stressful for your baby than directed pushing.

Pushing when and how your natural urge tells you to gives you the best chance of preventing tears and muscle weakness in your pelvis after the birth.

www.ncbi.nlm.nih.gov/pmc/articles/PMC1948091/

Finally, even if it's beneficial to push without a contraction (which goes against all advice I was ever given or read in pregnancy) there's no excuse for threatening to cut someone open in order to scare them into pushing a baby out, if that's even what she was doing. One does not ask for consent by telling them you're going to do something. The key word is ask.

[neonglow]

Yes- ‘I’m going to cut you’ does not fall into gaining informed consent by any stretch of the imagination.

[Pinkpanther473]

@RolytheRhino I get this. With dd1 I had bad 3rd degree tear. I had a doula which I am so grateful for and which made the birth less traumatic (induction after waters broke but contractions didn’t start).
We reflected on my 2nd delivery that there was a lot of pressure from the mw (plus mw student that I didn’t have a choice about accepting into the room) to push at the end so I did, in between contractions. With dc2 I ignored all the shouting to push at the end and just went with the contractions. Had a lovely mw second time round who said I did a good job breathing the baby out. No tear and I was up and about very soon after the birth.
With this pg I am under consultant care. I’m grateful for this but have found it difficult that she has not even discussed an instruction she has written in my notes re the early induction date. I had to prep the courage to look into it and ask for information about risk to me and baby for this course of action.
I have not met the same midwife twice in a row for this pg and this is why I’m happy to have my doula again who I know, who will chat to me about options beforehand and who will have my back to try and make sure these are respected if I’m too out of it.
Also cos I know and trust her, if she tells me calmly what the hcp’s are saying urgently or a bit alarmingly, I feel more able to relax and do it.

[Verily1]

I was refused entry to the labour ward unless I ‘consented’ to an unwanted and unnecessary internal.

Medics who ignore consent should be jailed for assault

[AthollPlace]

I consented to my section, but I was delirious due to pain and lack of sleep, drugged and drifting in and out of consciousness. I recall the doctor reading the consent form out loud but I was drifting mentally and wasn’t understanding or taking it in. So I stopped him and just said “If it makes the pain stop then I’ll sign it”. It would have been better to gain informed consent from my next of kin, because while I was technically conscious I wasn’t capable.

[PanamaPattie]

The reason why I have negative feelings towards Drs and MW is because each and everyone - without exception did not give one jot about me, my body or my health and well being. I've had 4 DC. My friends, relations and colleagues feel the same way. To be pregnant and to endure labour is like entering a battlefield when you have no amour and the enemy has tanks. The odds are against you. You cannot hope to win against the system.

I admire your "dedication" Central but what an interesting example you bring to the discussion. I wonder what other women in your care would say about you? I would be delighted to be proved wrong and it's just me that has had many bad experiences with your profession, but I don't think that will be the case.

[ABingThing]

Medical professionals aren't necessarily consistent.

The midwife who made no effort to stop the unconsented procedure on me then tried to justify it was, as far as I'm concerned, deeply unprofessional and shouldn't be allowed to continue in her role without further training.

The woman she helped deliver safely the next day might think she was the best midwife ever.

Both central and panama are correct: just because central has experience of herself and her colleagues behaving in a way she considers good, doesn't mean panama is wrong about the poor care she and others have received.

[5zeds]

I was treated appallingly in my last labour. The midwife refused to give me any pain relief beyond gas and air unless I got into a birthing pool which I had said I didn’t want. I was made to crawl down the corridor naked from the waist down to the birthing pool room. Once in she told me I couldn’t have any pain relief because I was now wet and it would take too long. I gave birth to a 9lb 10 back to back baby. It was my fifth child and I felt horrible about it for a long time. There is no protection from women like that.

[AnneElliott]

I agree that consent is a significant issue for pregnant women. I was told that the Consultant "wouldn't let me go overdue by more than 10 days".

I did get quite arsy about there was no "let" about it as I was an adult with capacity. That was waved away. I honestly think men wouldn't be treated in this way.

[ForeverFaff]

Wow. Seems like @MNHQ are once again happy to know what a woman is when it's time to use us as a resource, but won't let us talk about what doesn't make a woman on the feminism boards.
Are transwomen included in this consultation?

[Sagradafamiliar]

5 that was so cruel and calculated of her.
It reminds me of my first, when I was delivering a 9lb12 back to backer, I was literally pleading with the midwife, trying to bargain with her for some pain relief. She kept fobbing me off, putting terms on it and then when I asked again, changing the terms and telling all kinds of lies as to why I couldn't have any just yet. I'd rather her have said 'sorry but you can't have any because (insert reason here)' instead of putting me through hours of thinking I could have some, then being told I couldn't, then I could, then hours later, no not yet, soon, oh no, not just now, later on.
After I finally delivered, I was told that she'd been winking and laughing about it over my head where I couldn't see, so had never had any intention of allowing me any and was just having me on.

I had similar attitudes in another labour years after, where midwives told me they would like a 'nice, natural labour' for me. Nothing I could say would persuade them otherwise.

That's without the baby in between, who I delivered outside on the floor after having to leave after being threatened to escorted off the premises as they wouldn't believe I was in labour (don't think they had any beds), they were cooing and laughing afterwards about her being 'a surprise baby'. She wasn't a surprise to me!!

[5zeds]

@Sagradafamiliar it was outrageous and abusive. She had absolutely no regard for the birth I wanted and every intention of using her position to manipulate and control. I should be clear I have an extremely high pain threshold, and had had three successful vaginal deliveries so was not wimping out. The birthing pool was the end of many equally bullying tactics. She ruined my birthing experience. She had an idea in her head of what it should be like and what we should want and no understanding of anything very much. For balance my first midwife was everything you could want and more and 19 years later I often think her with gratitude.

[Tableclothing]

I had an extremely negative experience with a midwife in an antenatal appointment a couple of months ago. I am in the process of making a formal complaint to the Trust about it. I then inadvertently saw the same midwife again more recently (I panicked and didn't just get up and leave, got through the appointment by answering everything with one word answers). She did recognise me vaguely but clearly had no idea that I might not be thrilled to see her again. She obviously lacked any insight into the impact her actions had had on me.

It is incredibly difficult to even find out how to complain about a midwife. Google it and you end up at the NMC, but the NMC website tells you to try to complain at a local level first. Google "How to complain about a midwife [Trust]" sent me to a Trust page that advised me to talk to PALS. Googling PALS, I ended up at a page that told me to talk to my Trust. I probably would have given up at that point if I hadn't happened to have met, socially and completely by chance, a fairly senior person in the Trust who facilitated a meeting to get the ball rolling. God knows how much bad practice is going completely unreported.

There is no protection from women like that.

Feeling completely unable to trust midwives in general was quite a large factor in my decision to have ELCS.